Transcript - The department of cardiology, Calicut medical college

Cardio pulmonary resuscitation
• Cardiac arrest-abrupt cessation of cardiac pump
function,which may be reversible
• Most victims of SCA demonstrate ventricular
fibrillation (VF) at some point in their arrest.
• Resuscitation is most successful if defibrillation is
performed in about the first 5 minutes after collapse
• High survival rates depends on a public trained in CPR
and on well-organized public access defibrillation
programs
• Bystander CPR is performed in about only a third of
witnessed arrests.
Adult Basic Life Support
• BLS refers to maintaining airway patency and
supporting breathing and the circulation, without
the use of equipment other than a protective
device
• includes recognition of signs of sudden cardiac
arrest (SCA), heart attack, stroke, and foreignbody airway obstruction (FBAO);
cardiopulmonary resuscitation (CPR); and
defibrillation with an automated external
defibrillator (AED)
• American Heart Association uses 4 links in a chain -the
“Chain of Survival” to illustrate the important time
sensitive actions for victims of VF SCA.
• These links are
– Early recognition of the emergency and activation of local
emergency response system
– Early bystander CPR: immediate CPR can double or triple
the victim’s chance of survival from VF SCA.
– Early delivery of a shock with a defibrillator: CPR plus
defibrillation within 3 to 5 minutes of collapse can produce
survival rates as high as 49% to 75%
– Early advanced life support followed by postresuscitation
care delivered by healthcare providers.
Adult BLS Sequence
• Steps of BLS consist of a series of sequential
assessments and actions, which are illustrated
in the BLS algorithm
Open the Airway: Lay Rescuer
• Head tilt– chin lift maneuver for both injured
and noninjured victims.
• The jaw thrust is no longer recommended for
lay rescuers
– Is difficult for lay rescuers to learn and perform
– Is often not an effective way to open the airway
– May cause spinal movement
Open the Airway: Healthcare Provider
• Head tilt– chin lift maneuver to open the
airway of a victim without evidence of head or
neck trauma.
• If cervical spine injury is suspected , open the
airway using a jaw thrust without head
extension
• Use a head tilt– chin lift maneuver if the jaw
thrust does not open the airway
Basic airway management
Head tilt and chin lift
Basic airway management
Head tilt and chin lift
Basic airway management
Jaw thrust
Check Breathing
• Look, listen, and feel for breathing.
• Adequate breathing is not detected within 10
seconds, give 2 breaths
• If you are a lay rescuer and you are unwilling
or unable to give rescue breaths, begin chest
compressions .
• Treat the victim who has occasional gasps as if
he or she is not breathing and give rescue
breaths.
• Give 2 rescue breaths, each over 1 second, with
enough volume to produce visible chest rise.
• recommendations for delivery of rescue breaths
during cardiac arrest as follows
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Deliver each rescue breath over 1 second
Give a sufficient tidal volume to produce visible chest rise
Avoid rapid or forceful breaths.
When an advanced airway (ie, endotracheal tube,
Combitube, or LMA) is in place during 2-person CPR,
ventilate at a rate of 8 to 10 breaths per minute without
attempting to synchronize breaths between compressions
Mouth-to-Mouth Rescue Breathing
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Open the victim’s airway
Pinch the victim’s nose
Create an airtight mouth-to-mouth seal.
Give 1 breath over 1 second
Take a “regular” (not a deep) breath
Give a second rescue breath over 1 second
Despite its safety, some may hesitate to give
mouth-to-mouth rescue breathing and prefer to
use a barrier device
Mouth-to-Nose Ventilation
• Recommended if it is impossible to ventilate
through the victim’s mouth,mouth cannot be
opened or a mouth-to-mouth seal is difficult
to achieve
• Feasible, safe, and effective
Ventilation With Bag and Mask
• Simultaneously open the airway with a jaw lift,
hold the mask tightly against the patient’s face,
and squeeze the bag.
• The rescuer must also watch to be sure the chest
rises with each breath
• Most effective when provided by 2 trained and
experienced rescuers
• Rescuer delivers the breaths during pauses in
compressions and delivers each breath over 1
second
Ventilation With an Advanced Airway
• Advanced airway devices such as the LMA and the
esophageal-tracheal combitube are currently within the
scope of BLS practice in a number of regions
• An advanced airway in place during CPR, 2 rescuers no
longer deliver cycles of CPR . instead,
– The compressing rescuer should give continuous chest
compressions at a rate of 100 per minute without pauses for
ventilation.
– The rescuer delivering ventilation provides 8 to 10 breaths per
minute.
– The 2 rescuers should change compressor and ventilator roles
approximately every 2 minutes
– When multiple rescuers are present, they should rotate the
compressor role about every 2 minutes.
Foreign-Body Airway Obstruction
(Choking)
• Recognition of airway obstruction is the key to
successful outcome, it is important to distinguish this
emergency
• If mild obstruction is present and the victim is coughing
forcefully, do not interfere with the patient’s
spontaneous coughing and breathing efforts
• Intervene if signs of severe obstruction develop
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The cough becomes silent
Respiratory difficulty increases
Accompanied by stridor
The victim becomes unresponsive.
• Chest thrusts, back slaps, and abdominal thrusts
are feasible and effective for relieving severe
FBAO in conscious (responsive) adults and
children 1 year of age
• Abdominal thrust- applied in rapid sequence until
the obstruction is relieved
• If abdominal thrusts are not effective, the rescuer
may consider chest thrusts
• Abdominal thrusts are not recommended for
infants < 1 year of age because thrusts may cause
injuries
• If victim with FBAO becomes unresponsive, the rescuer
should carefully support the patient to the ground,
immediately activate EMS and then begin CPR.
• Higher sustained airway pressures can be generated
using the chest thrust rather than the abdominal thrust
• Each time the airway is opened during CPR, the rescuer
should look for an object in the victim’s mouth and
remove it
• Use a finger sweep only when the provider can see
solid material obstructing the airway of an
unresponsive patient (class indeterminate)
chest thrusts
chest thrusts
Foreign body airway obstruction (FBAO)
abdominal thrusts
Foreign body airway obstruction (FBAO)
abdominal thrusts
Foreign body airway obstruction (FBAO)
back slaps
Rescue Breathing Without Chest
Compressions
• If an adult victim with palpable pulses
requires support of ventilation, give rescue
breaths at a rate of 10 to 12 breaths per
minute
• Reassess the pulse approximately every 2
minutes
Chest Compressions
• Chest compressions consist of rhythmic
applications of pressure over the lower half of the
sternum
• Blood flow generated by chest compressions
delivers a small but critical amount of oxygen and
substrate to the brain and myocardium
• In VF chest compressions increase the likelihood
that an attempted defibrillation will be successful
• Chest compressions are especially important if
the first shock is delivered 4 minutes after
collapse
• “Effective” chest compressions are essential for
providing blood flow during CPR
• to give “effective” chest compressions, “push
hard and push fast.” Compress at a rate of about
100 compressions per minute, with a
compression depth of 4 to 5 cm
• Allow chest to recoil completely after each
compression, and allow approximately equal
compression and relaxation times.
• Minimize interruptions in chest compressions.
Chest compressions
Chest compressions
Chest compressions
Chest compressions
Compression-Ventilation Ratio
• A compression-ventilation ratio of 30:2 is
recommended.
• In infants and children 2 rescuers should use a
ratio of 15:2
• Once an advanced airway is in place, 2
rescuers no longer deliver cycles of CPR
• CPR prompt device may be useful in improving
quality of CPR
Compression-Only CPR
• Laypersons should be encouraged to do compression-only
CPR if they are unable or unwilling to provide rescue breaths,
although the best method of CPR is compressions coordinated
with ventilations.
• Survival rates were better with chest compressions only than
with no CPR.
• Rescue breathing is not essential during the first 5 minutes of
adult CPR for VF.
• If the airway is open, occasional gasps and passive chest recoil
may provide some air exchange.
• In addition, a low minute ventilation may be all that is
necessary to maintain a normal ventilation-perfusion ratio
during CPR.
Defibrillation
• Early defibrillation is critical to survival from sudden
cardiac arrest (SCA) for several reasons:
– The most frequent initial rhythm in witnessed SCA
is ventricular fibrillation (VF)
– The probability of successful defibrillation
diminishes rapidly over time
– VF tends to deteriorate to asystole within a few
minutes.
• For every minute that passes between collapse and
defibrillation, survival rates from witnessed VF SCA
decrease 7% to 10% if no CPR is provided
• When bystander CPR is provided, the decrease in
survival rates is more gradual and averages 3% to 4%
per minute
• CPR can double or triple survival from witnessed SCA at
most intervals to defibrillation.
• CPR prolongs VF(ie, the window of time during which
defibrillation can occur) and provides a small amount
of blood flow that may maintain some oxygen and
substrate delivery to the heart and brain
Shock First Versus CPR First
• When any rescuer witnesses an out-of-hospital arrest
and an AED is immediately available on-site, the
rescuer should use the AED as soon as possible
• Healthcare providers who treat cardiac arrest in
hospitals and other facilities with AEDs on-site should
provide immediate CPR and should use the
AED/defibrillator as soon as it is available
• When an out-of-hospital cardiac arrest is not witnessed
by EMS personnel, they may give about 5 cycles of CPR
before checking the ECG rhythm and attempting
defibrillation particularly when call-to-response
interval is > 5 min.
• When VF is present for more than a few
minutes, the myocardium is depleted of
oxygen and metabolic substrates. A brief
period of chest compressions can deliver
oxygen and energy substrates, increasing the
likelihood that a perfusing rhythm will return
after defibrillation
1-Shock Protocol Versus 3-Shock
Sequence
• Interruption in chest compressions is associated with a
decreased probability of conversion of VF in the 3-shock
sequence.
• Rhythm analysis of 3-shock sequence performed by
commercially available AEDs revealed delays of up to 37
seconds between delivery of the first shock and delivery of
the first post-shock compression
• Animal studies documented harmful effects from
interruptions to chest compressions
• The rescuer should not delay resumption of chest
compressions to recheck the rhythm or pulse. After 5 cycles
(about 2 minutes) of CPR, the AED should then analyze the
cardiac rhythm and deliver another shock if indicated.
• The rescuer providing chest compressions
should minimize interruptions in chest
compressions for rhythm analysis and shock
delivery
• When 2 rescuers are present, the rescuer
operating the AED should be prepared to
deliver a shock as soon as the compressor
removes his or her hands from the victim’s
chest
• Monophasic Waveform Defibrillators
– deliver current of one polarity (ie,direction of current
flow).
• Biphasic Waveform Defibrillators
– lower-energy biphasic waveform shocks have equivalent or
higher success for termination of VF than monophasic
waveform shocks delivering escalating energy (200 J, 300 J,
360 J) with successive shocks.
– it is reasonable to use selected energies of 150 J to 200 J
with a biphasic truncated exponential waveform or 120 J
with a rectilinear biphasic waveform for the initial shock.
Automated External Defibrillators
• AEDs are sophisticated, reliable computerized
devices that use voice and visual prompts to
guide lay rescuers and healthcare providers to
safely defibrillate VF SCA
• Lay rescuer AED programs to improve survival
rates from out-of-hospital SCA
• AEDs are of no value for arrest not caused by
VF/pulseless VT, and they are not effective for
treatment of nonshockable rhythms that may
develop after termination of VF
Safe use of oxygen during defibrillation
• Take off any oxygen mask/nasal cannulae & place
them at least 1m away from the patient’s chest.
• Leave the ventilation bag connected to the
tracheal tube or other airway adjunct.
• Alternatively, disconnect any bag-valve device
from the tracheal tube (or other airway adjunct)
and remove it at least 1m from the patient’s
chest during defibrillation
• Minimise the risk of sparks during defibrillation.
• Self-adhesive defibrillation pads are less likely to
cause sparks than manual paddles.
Electrode-patient interface
• Transthoracic impedance (TTI)varies with body
mass- approximately 70—80 Ω in adults
• To reduce transthoracic impedance, the
defibrillator operator should use conductive
materials
• Paddles should be well separated, and the paste
or gel should not be smeared on the chest
between the paddles
• Defibrillation for patients with permanent
pacemakers or ICDs, do not place the electrodes
over or close to the device generator
• Pacemakers and ICDs should be reevaluated after
the patient receives a shock
• Paddle electrodes and self-adhesive pad
electrodes 8 to 12 cm in diameter perform
well, although defibrillation success may be
higher with electrodes 12 cm in diameter
rather than with those 8 cm in diameter
Electrode position
Pads versus paddles
• No evidence that attempting to “defibrillate”
asystole is beneficial
• Studies revealed the group that received shocks
showed a trend toward a worse outcome than the
group that did not receive shocks.
• With recent recognition of the importance of
minimizing interruptions in chest compressions,
attempt shock delivery for asystole is not
recommended
Synchronized Cardioversion
• Synchronized cardioversion is shock delivery that
is timed (synchronized) with the QRS complex
• Must be synchronised to occur with the R wave of
the ECG rather than with the T wave:
• VF can be induced if shock is delivered during the
relative refractory portion of the cardiac cycle.
• Synchronisation can be difficult in VT because of
the wide-complex & variable forms of ventricular
arrhythmia.
• If synchronisation fails, give unsynchronised
shocks to the unstable patient in VT to avoid
prolonged delay in restoring sinus rhythm.
• Ventricular fibrillation or pulseless VT requires
unsynchronised shocks.
Pacing
• Pacing is not recommended for patients in
asystolic cardiac arrest.
• Pacing can be considered in patients with
symptomatic bradycardia.
Adult advanced life support
• Advanced life support is aimed to revert
cardiac rhythm to one that is
hemodynamically effective,optimise
ventilation,maintain and support
circulation
Shockable rhythms (VF/pulseless VT)
• If VF/VT is confirmed, give 1shock
(150—200-J biphasic or 360-J
monophasic).
• Without reassessing the rhythm or
feeling for a pulse, resume CPR
(30:2)immediately after the shock,
starting with chest compressions.
• Continue CPR for 2 min, then pause
briefly to check the monitor: if there
is still VF/VT, give a second shock
(150—360-J biphasic or 360-J
monophasic).
• Resume CPR immediately after the
second shock.
• Pause briefly after 2 min of CPR to check
monitor: if still VF/VT, → adrenaline
followed immediately by a third shock
(150—360-J biphasic or 360-J
monophasic) and resumption of CPR
(drug-shock-CPR-rhythm check sequence)
• After drug delivery and 2 min of CPR,
analyse rhythm.
• If VF/VT persists after the third shock,
give an IV bolus amiodarone 300 mg.
• Inject amiodarone during the brief
rhythm analysis before delivery of the
fourth shock.
• Rhythm checked 2 min after a shock → nonshockable
rhythm is present and the rhythm is organised
(complexes appear regular or narrow), try to palpate
a pulse. Rhythm checks must be brief, and pulse
checks undertaken only if an organised rhythm is
observed.
• If an organised rhythm is seen during a 2 min period
of CPR, do not interrupt chest compressions to
palpate a pulse unless the patient shows signs of life
suggesting ROSC.
• If there is any doubt about the presence of a pulse in
the presence of an organised rhythm, resume CPR.
• If the patient has ROSC, begin postresuscitation care.
• Regardless of the arrest rhythm, give
adrenaline 1mg every 3—5 min until ROSC is
achieved
• This will be once every two loops of the
algorithm.
Persistent ventricular fibrillation
• In VF persists, consider changing the position
of the paddles.
• Review all potentially reversible causes and
treat any that are identified.
Non-shockable rhythms (PEA and asystole)
• Start CPR 30:2 and give adrenaline 1mg as soon
as iv access is achieved
• Despite the lack of evidence that routine
atropine for asystolic cardiac arrest increases
survival, give atropine 3mg (the dose that will
provide maximum vagal blockade) if there is
asystole or the rhythm is slow PEA (rate <60
min−1)
• After 2 min of CPR, If no rhythm is present
(asystole), or if there is no change in the ECG
appearance, resume CPR immediately.
• If an organised rhythm is present, attempt to
palpate a pulse. If no pulse (or if there is any
doubt about the presence of a pulse), continue
CPR.
• If signs of life return during CPR, check the
rhythm and attempt to palpate a pulse
• If a pulse is present, begin post-resuscitation
care.
• If there is doubt about whether the rhythm is
asystole or fine VF, do not attempt defibrillation;
instead, continue chest compressions and
ventilation.
• Fine VF that is difficult to distinguish from
asystole will not be shocked successfully into a
perfusing rhythm
• Intravenous access and drugs
Central venous v/s Peripheral drug delivery
• +peak drug concentrations are higher
• +circulation times are shorter
• -insertion of a CV catheter requires interruption
CPR
• -is associated with several complications.
• +quicker, easier to perform and safer.
• -Drugs injected must be followed by a flush of at
least 20 ml of fluid and elevation of the extremity
for 10—20 s to facilitate drug delivery to the
central circulation
Intraosseous route.
• Achieves adequate plasma concentrations in a
time comparable with injection through a
central venous catheter
• Also enables withdrawal of marrow for venous
blood gas analysis and measurement of
electrolytes & Hb concentration.
Tracheal route
• During CPR, the equipotent dose of adrenaline
given via the trachea is 3-10 times ↑ than the IV
dose
• If given via the trachea, adrenaline dose is 3mg
diluted to at least 10 ml with sterile water.
• Dilution with water instead of 0.9% saline may
achieve better drug absorption
Potentially reversible causes
• Minimise the risk of hypoxia by ensuring that
the patient’s lungs are ventilated adequately
with 100% oxygen
• Hypovolemia-restore intravascular volume
rapidly with fluid,coupled with urgent surgery
• Intravenous calcium chloride -hyperkalaemia,
hypocalcaemia,calcium-channel-blocking drug
overdose.
• Tension pneumothorax-needle thoracocentesis,chest
drain
• Cardiac tamponade-needle pericardiocentesis,
thoracotomy.
• Toxic substances-appropriate antidotes
• Thromboembolic -Thrombolysis may be considered in
adult cardiac arrest, on a case-by-case basis, following
initial failure of standard resuscitation in patients in
whom an acute thrombotic etiology for the arrest is
suspected.
• Intravenous fluids-initial stages of resuscitation there
are no clear advantages to using colloid: use saline
Monitoring and Medications
• Arterial blood gas monitoring-not a reliable
indicator of the severity of tissue hypoxemia
• No clinical utility of checking pulses during
ongoing CPR
• End-tidal CO2 monitoring is a safe and
effective noninvasive indicator of cardiac
output during CPR and may be an early
indicator of ROSC in intubated patients
Postresuscitation Support
• Optimize cardiopulmonary function and
systemic perfusion,especially perfusion to the
brain
• Transport the victim of out-of-hospital cardiac
arrest to the hospital emergency department
• To identify the precipitating causes of the arrest
• Institute measures to prevent recurrence
• Institute measures that may improve long-term,
neurologically intact survival
• Induced Hypothermia-Unconscious adult
patients with spontaneous circulation after
out-of-hospital VF cardiac arrest should be
cooled to 32-34°C for at least 12-24 h.
• Glucose Control-4.4 - 6.1 mmol/l using insulin
• Organ-Specific Evaluation and Support
• Mechanical ventilation
CPR Techniques and Devices
• High-frequency chest compressions (HFCC)
– High-frequency (>100 compressions min−1)
manual or mechanical chest compressions
improve haemodynamics but have not been
shown to improve longterm outcome.
Interposed abdominal compression (IAC-CPR)
Open-chest CPR
• Open-chest CPR
– for patients with cardiac arrest in the early
postoperative period after cardiothoracic surgery
– when the chest or abdomen is already open
“Cough” CPR
• Not useful for the treatment of an
unresponsive victim
• Human “cough” CPR has been reported only in
awake,monitored patients who developed
ventricular fibrillation (VF) or rapid ventricular
tachycardia
• Can maintain consciousness for up to 90
seconds.
Precordial thump
• Single precordial thump may be given for a witnessed
and monitored sudden collapse, and a defibrillator is
not immediately to hand.
• Should be undertaken immediately after confirmation
of cardiac arrest
• Ulnar edge of a tightly clenched fist used to deliver a
sharp impact to the lower half of the sternum from a
height of about 20 cm, then retract immediatelymost
likely
• May succeed in converting VT to sinus rhythm
• Successful treatment of VF by precordial thump is
much less likely:
Active compression-decompression CPR
(ACD-CPR)
• Active compression-decompression CPR (ACDCPR) is performed with a hand-held device
equipped with a suction cup to actively lift the
anterior chest during decompression.
• It is thought that decreasing intrathoracic
pressure during the decompression phase
enhances venous return to the heart
• May be considered for use in the in-hospital
setting when providers are adequately trained
(Class IIb).
Impedance threshold device (ITD)
• Valve that limits air entry into the lungs during
chest recoil between chest compressions.
• Designed to reduce intrathoracic pressure and
enhance venous return to the heart.
• ITD as an adjunct to CPR in intubated adult
cardiac arrest patients can improve
hemodynamic parameters(Class IIa).
Impedance threshold device (ITD)
Mechanical piston CPR
Mechanical piston CPR
Load-distributing band CPR or vest
CPR
• The load-distributing band (LDB) is a
circumferential chest compression device
composed of a pneumatically or electrically
actuated constricting band and backboard
Phased thoracic—abdominal
compression—decompression CPR
(PTACD-CPR)
• Phased thoracic-abdominal compressiondecompression CPR (PTACD-CPR) combines
the concepts of IAC-CPR and ACD-CPR
• A hand-held device alternates chest
compression and abdominal decompression
with chest decompression and abdominal
compression
Cardiocerebral resuscitation (CCR)
• Cardiocerebral resuscitation (CCR) represents
a bundle of specific therapies designed to
enhance perfusion during cardiopulmonary
arrest by emphasizing chest compressions
over ventilations and “priming” the heart with
compressions before and after defibrillation
attempts.
Thank you